India prevented 1 million deaths among children under five years of age between 2005 and 2015. Three million more deaths could have been prevented had all of India performed as well as some states, a new study published in the international health journal Lancet on September 19 said.

Interventions including timely treatment in the case of diarrhoea, vaccinations for tetanus and measles, and an increase in hospital births have enabled this improvement, one of the study’s authors told IndiaSpend.

Marked improvement

The mortality rate for neonates—children below 28 days of age–fell 40% from 45 per 1,000 live births in 2000 to 27 in 2015. Meanwhile, the mortality rate among children older than 1 month but younger than 5 years (1-59 months) was 45.2 per 1,000 live births in 2000 which fell to 19.6 in 2015, a 56% reduction.

Mortality rates from neonatal tetanus and measles fell by at least 90%, while neonatal infection and birth trauma fell more than 66%. For children aged 1-59 months, mortality rates from pneumonia and diarrhoea fell more than 60%.

These findings are from Million Death Study, a large-scale study of premature deaths in India. More than 900 Census surveyors visited some 1.3 million households across 7,000 randomly selected areas and conducted ‘verbal autopsies’—interviews to find the causes of deaths recorded.

Implemented by the Registrar General and Census Commissioner of India, verbal autopsies are used in low-income countries where deaths are often not documented. Nearly 75% of the estimated 9.5 million deaths each year in India occur at home, half of which do not have a certified cause.

The most significant finding of the study is the faster decline in deaths due to the conditions that got the most attention, such as pneumonia, diarrhoea, measles, tetanus and birth infections. Interventions including timely treatment in the case of diarrhoea, vaccinations for tetanus and measles, and an increase in hospital births have enabled this improvement, Prabhat Jha, senior author of the study and head of the Centre for Global Health Research at St. Michael’s Hospital in Toronto, Canada, told IndiaSpend in an email.

The study recorded mortality rates for neonates, children between 1 to 59 months, and children under five (which adds both) separately. Trends in mortality rates of girls v. boys, urban v. rural areas and richer v. poorer states were also recorded.

Fewer deaths from infectious disease, but more children born underweight

The fewer deaths of children under the age of five are mostly thanks to decline in incidence of infectious diseases.

From 2000 to 2015, interventions were more successful in saving lives of children aged 1-59 months than neonates. Neonatal deaths fell 3.3% every year while 1-59 months deaths fell 5.4%.

Among children aged 1-59 months, there were fewer deaths due to pneumonia (62%), diarrhoea (65%), other infectious (38%) and nutritional conditions (26%), but there was no significant change in the number of deaths from noncommunicable diseases and injuries.

Meanwhile, neonatal deaths, which were 50% of all child deaths in 2000, increased to 58% in 2015.

Even as incidence of neonatal infection reduced by 66% and birth asphyxia and trauma by 75%, 16% more babies were born premature or underweight. Most neonatal deaths–370,000 in 2015–were attributed to this.

These low birth weight babies require additional health check-ups after the 48-hour hospitalization mandated under Janani Suraksha Yojana, a safe motherhood programme that promotes institutional deliveries, Jha said. Since deaths among premature and underweight babies have increased in rural areas and poorer states more than in urban areas or richer states, they are avoidable, he added.

Low birth weight can be avoided by improving antenatal care, parents’ and families’ education and awareness, and mother’s nutrition (particularly to treat anaemia), as well as addressing other factors such as mother’s use of oral tobacco, the study noted.

Most of the deaths due to low birth weight occurred among babies born at full term. The reasons need more study, Jha said, adding that a working group at the Indian Council of Medical Research is studying examining this.

Poor and rural areas fare worse

Both rural and urban areas have recorded a 47% decrease in child mortality from 2000 to 2015.

Of these, 850,000 (70%) were in poorer states while 347,000 (28%) in richer states.

‘Poorer’ states are those with poor economic social indicators–Assam, Bihar, Chhattisgarh, Uttar Pradesh, Uttarakhand, Jharkhand, Madhya Pradesh, Odisha and Rajasthan. The rest are considered ‘richer’ states.

From 2000 to 2015, child mortality rate decreased by 47% in poorer states and 51% in richer states.

Prematurity and low birth weight increased in rural areas (from 13.2 per 1000 live births in 2000 to 17 in 2015) and poorer states (from 11.3 per 1000 live births in 2000 to 17.8 in 2015) and decreased in urban and richer states.

If all states of India had achieved the improvements seen in Tamil Nadu, Karnataka and Maharashtra, nearly all states of India would have met the 2015 Millennium Development Goals, the study noted.

Girls v. boys

Under-five child mortality rates have been significantly higher among girls than among boys. In 2000, 95 girls and 85 boys died per 1,000 births; in 2015, the gap narrowed so that 48 girls and 45 boys died per 1,000 births. This could be due to free treatment made available under National Health Mission, Jha said.

There has been a 49% reduction in mortality rate among girls under five and a 47% reduction in mortality among boys under five from 2000 to 2015.

Closer to meeting SDG targets

India’s next challenge is to meet the 2030 Sustainable Development Goals (SDGs)–which countries have agreed upon under the aegis of the United Nations Development Programme–on child and neonatal mortality. The SDG is to reduce child mortality to 25 per 1,000 live births and neonatal mortality to 12 per 1,000 live births.

This would require an average annual decline of 4.1% in child mortality and 5.3% in neonatal mortality from 2015 onwards, the study noted.

India could achieve this by improving education, antenatal care and nutrition, and reducing maternal anaemia and tobacco use, as mentioned earlier.

Under its Newborn Action Plan launched in 2014, India must also pay more attention to the neonatal period, by providing early home visits by health professionals, for instance, the study noted. It must also conduct more research on interventions for prematurity and low birthweight to end preventable newborn deaths by 2030.

(Yadavar is a principal correspondent with IndiaSpend.)

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India has done well to reduce child death numbers appreciably but the poorer states are still a cause of concern. Government should take special care in implementing neonatal, natal and child welfare policy and programs. By increasing the accessibility of medical care, poorer states can also reduce the number thereby reducing overall deaths.